J. Christopher Perry

An Empirical Study of Defense Mechanisms: I. Clinical Interview and Life Vignette Ratings

The Defense Mechanism Rating Scales (DMRS) measure the use of defense mechanisms based on clinical interview or life vignette data. Using nonprofessional raters observing videotaped psychodynamic interviews of individuals with personality and affective disorders, the median intraclass interrater reliability (IR) of the defense scales was .36 but was .57 for group consensus ratings and .74 when related defenses were grouped into defense summary scales. When follow-up data on life vignettes were rated, the median interrater IR was .55 for those defenses occurring at least 5% of the time and .66 for the defense summary scales. In relation to follow-up data, so-called immature defenses (denial, projection, acting out, hypochondriasis, passive-aggression) were associated with higher levels of symptoms, poorer global functioning, and higher proportion of time impaired in psychosocial role functioning. Borderline defenses (splitting, projective identification) displayed a similar pattern. Among narcissistic and neurotic defenses, only devaluation was associated with poorer functioning, whereas intellectualization was associated with higher functioning. Finally, action and borderline defenses demonstrated significant correlations across methods and across time (video vs life vignettes), whereas obsessional, disavowal, and narcissistic defenses showed nonsignificant trends. Overall, these results support the model of a hierarchy of defenses.

Validating Antonovsky's Sense of Coherence Scale.

This study empirically supported Antonovskys predictions that a persons Sense of Coherence is implicated in coping with life stresses and psychological distress. Sense of Coherence scales accounted for as much variance in criterion measures of Life Events stressors, Depression, and Anxiety as did traditional locus of control and social support predictor measures. Sense of Coherence scales emerged as useful additions for studies of personality characteristics implicated in personal reactions to distressing life events.

A preliminary report on defenses and conflicts associated with borderline personality disorder.

The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each subject was videotaped, from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominant other and dominant goal. Chronic depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of these findings is discussed.

Instruments for the assessment of childhood trauma in adults

The relationship between childhood trauma and adult psychopathology has been explored in the literature. The goal of this study is to compare existing instruments that measure retrospective interpersonal gross childhood trauma. A computerized search from 1985 to March 2003 was performed to locate instruments used to measure childhood trauma. These were divided into interview-rated and self-report measures and were compared on various parameters. Twenty-one observer-rated and 21 self-report instruments were identified. In a comparison, five observer-rated measures and three self-report measures stand out for having favorable characteristics such as assessing multiple types of trauma and reporting on psychometric properties. A number of instruments are designed to measure a single type of trauma, usually sexual abuse, but most of these do not report psychometric properties. A few instruments used to measure retrospective childhood trauma are particularly useful for systematic research in adult psychiatric disorders.

A pilot study of defenses in adults with personality disorders entering psychotherapy.

This study examined defensive functioning in adults entering open-ended dynamic psychotherapy and determined whether defenses predict retention at 1 year. Beginning at about the fifth session, 14 adults with personality and or depressive disorders entering open-ended dynamic psychotherapy had five therapy sessions audiotaped. The sessions were rated according to the Defense Mechanism Rating Scales, quantitative method. Interrater reliability of overall defensive functioning (ODF) and the number of defenses used per session were intraclass R = .85 and .83, respectively, whereas that of seven defense levels yielded a median of .625 (range .52 to .80). Stability of ODF across the five sessions was intraclass R = .48. The 11 subjects with personality disorders (PDs) used predominantly lower immature (49.3%) and neurotic (40.8%) level defenses. Subjects with borderline PD had significantly lower ODF than those with other PD types. Higher ODF was associated with remaining in treatment at 1 year, although this was confounded with a higher frequency of weekly sessions. Quantitative assessment of defenses demonstrated fair to excellent reliability and indicated that in the short term approximately half of defensive functioning reflects a stable repertoire, whereas the remaining variation may be due to occasion and error. PDs and especially BPD are characterized by a predominance of lower defenses. Higher defensive functioning was associated with twice-weekly sessions and retention in therapy at 1 year. In therapy, adjusting technique to the patients defenses may improve retention and outcome.This study examined defensive functioning in adults entering open-ended dynamic psychotherapy and determined whether defenses predict retention at 1 year. Beginning at about the fifth session, 14 adults with personality and or depressive disorders entering open-ended dynamic psychotherapy had five therapy sessions audiotaped. The sessions were rated according to the Defense Mechanism Rating Scales, quantitative method. Interrater reliability of overall defensive functioning (ODF) and the number of defenses used per session were intraclass R = .85 and .83, respectively, whereas that of seven defense levels yielded a median of .625 (range .52 to .80). Stability of ODF across the five sessions was intraclass R = .48. The 11 subjects with personality disorders (PDs) used predominantly lower immature (49.3%) and neurotic (40.8%) level defenses. Subjects with borderline PD had significantly lower ODF than those with other PD types. Higher ODF was associated with remaining in treatment at 1 year, although this was confounded with a higher frequency of weekly sessions. Quantitative assessment of defenses demonstrated fair to excellent reliability and indicated that in the short term approximately half of defensive functioning reflects a stable repertoire, whereas the remaining variation may be due to occasion and error. PDs and especially BPD are characterized by a predominance of lower defenses. Higher defensive functioning was associated with twice-weekly sessions and retention in therapy at 1 year. In therapy, adjusting technique to the patients defenses may improve retention and outcome.

A study of stability and change in defense mechanisms during a brief psychodynamic investigation.

This study investigated the stability of defensive functioning over the course of a 4-session Brief Psychodynamic Investigation (BPI). The sample included 61 outpatients from the Adult Psychiatry Department of the University of Lausanne, Switzerland. Defenses were measured from session transcripts using the DMRS quantitative method. Specific changes in defenses were found over the course of the ultrabrief investigation. First, the overall defensive functioning (ODF) score and the proportion of obsessional level defenses increased significantly, with a significant increase in intellectualization. Second, the number of defenses used and the proportion of narcissistic level defenses decreased, with a decreasing prevalence of devaluation and idealization. Third, high adaptive (mature) level defenses increased then decreased over the course of BPI, returning to their level at intake by the 4th session. Relief from distress and attending to the tasks of BPI tends to improve defensive functioning, but more likely returns it to usual levels rather than producing permanent change. Future studies will need to use designs that allow estimation of state changes while taking sufficient measurements to estimate potential changes in trait levels of defenses.

Observer‐Rated Measures of Defense Mechanisms

Observer-rated measures of defense mechanisms are the direct lineal descendants of Freuds clinical proposition that an observer can reasonably infer defensive operations in an individual of which the individual himself or herself is unaware. Assessment methods of defenses have used both projective testing and clinical interview data. Recent Rorschach test methods have focused on borderline and neurotic-level defenses used to discriminate diagnostic groups and predict other aspects of functioning. A TAT method has demonstrated some evidence for age progression in the development of defensive functioning and for regression in defensive functioning following psychological stress. While interrater reliability is generally good, the methods are limited by the availability of the testing situation and the need to demonstrate generalization to external situations. Following the early introduction of systematic methods by Haan and Vaillant, a number of methods use clinical interview data to assess specific defenses and overall defensive functioning. These methods identify defenses either as qualitative categories, rank-ordered scores by Q-sort, or actual counts of each instance a defense is used. Summary scores are generally of good reliability, with wider variation for individual defenses. There is wide variation on training required, ease of use, and levels of validation. A review of some correlates of each method suggests that the instruments have a robust potential for use in fundamental and applied clinical research. While each method has some clear applications, the quantitative clinical interview methods appear best adapted to microanalytic process research on issues of defensive change in treatment.

Change in Defense Mechanisms During Long-Term Dynamic Psychotherapy and Five-Year Outcome

OBJECTIVE Research suggests that defense mechanisms may underlie other aspects of functioning and psychiatric symptoms. The authors examined whether defenses change in accordance with the hierarchy of defense adaptation during long-term dynamic psychotherapy and whether such change is associated with long-term outcomes on other measures. METHOD Twenty-one adults with depressive, anxiety, and/or personality disorders entered long-term dynamic psychotherapy (mean=248 weeks) and subsequent follow-along (mean duration, 5.1 years). Measures of functioning and symptoms were gathered in periodic follow-along interviews, external to the therapy. A median of eight psychotherapy sessions over 2.5 years for each participant were rated using the Defense Mechanism Rating Scales quantitative method. RESULTS Overall, the lowest (action) and highest (high adaptive) defense levels in the hierarchy of defenses improved significantly, as did overall defensive functioning (median effect size=0.71, 95% CI=0.01-1.83). Overall defensive functioning still remained below the healthy-neurotic range. A higher number of axis I disorders and childhood histories of sexual abuse and witnessing violence were associated with a slower rate of improvement in defenses. Change in defenses within therapy by 2.5 years was highly associated with significant levels of change at 5 years in external measures of both functioning (rs=0.60) and symptoms (rs=0.58), controlling for initial levels. CONCLUSIONS Change in defensive functioning in long-term psychotherapy largely follows the hierarchy of defense adaptation. The relationship to long-term improvement in outcomes suggests that defenses be considered candidates for mediating improvement in functioning and symptoms.

Unwanted infants: Psychological and physical consequences of inadequate orphanage care 50 years later

Studies of the effects in middle-aged adults of institutionalization at birth or early childhood are rare. The results of this study show that members of a randomly selected, middle-aged group of orphans, most of whom were institutionalized at birth, were significantly more psychosocially dysfunctional and had significantly more chronic illnesses that could be stress related than a randomly selected, matched community sample.

A Markov model for predicting levels of psychiatric service use in borderline and antisocial personality disorders and bipolar type II affective disorder

This study examines the relationship between borderline personality disorder (BPD) and the use of psychiatric services in a naturalistic follow-up comparison with antisocial personality disorder and bipolar type II affective disorder. In the first follow-up series, borderline psychopathology was associated with higher levels of psychiatric service use (emergency, daycare, and inpatient). Markov analyses indicated that the transition between levels of psychiatric service use followed a stationary, second order process (i.e. the immediate past and current service use, predicted use on the next follow-up, and the relationship did not depend on the point in time examined in the follow-up series). Further, the transition probabilities generated from this model did not depend significantly on diagnosis. Predictions from the Markov model about the cumulative probability that subjects would use the highest level of psychiatric services were tested on a second series of follow-ups on the same subjects 20 months later. The model-based predictions (starting from the observed levels in the first two follow-ups of the second series) clustered into three groups, of high, middle, and low predicted probabilities. The subject group with the lowest predicted likelihood had a cumulative probability of 0.19 for using emergency, daycare, or inpatient hospitalization by 22 months of follow-up, whereas the group with the highest likelihood (containing a disproportionate number of BPD subjects) had a cumulative observed probability of 0.80. The Markov model generated from this second series supported the stationarity of the transition process. BPD subjects began using high levels of psychiatric services, but their transition from one level to another over time followed a process similar to that of non-BPD subjects.